Free Form AU-473 - New York

Reimbursement Application for Petroleum Business Tax on Fuel Used for Commercial Gallonage
Tax Law -- Article 13-A Complete Schedules A and/or B on back.
Name of claimant Street address For office use only City, state, and ZIP code Social security number Federal employer identification number Name of business NYS sales tax identification number Type of business Total approved Audited by Approved by Approved by Telephone number For Tax Period: Beginning

AU-473
(10/01)

(

)

Ending

Date Date Date

Computation of reimbursement --

Enter the number of gallons of fuel purchased for use as commercial gallonage in New York State on which the supplemental petroleum business tax was paid or absorbed. Note: Effective April 1, 2001, commercial gallonage does not include fuel used for nonresidential heating. 1 2 3 4 5 x

1 Gallons of diesel motor fuel (from Schedule A, line 3, on back) .............................................................................. 2 Gallons of residual petroleum product (from Schedule B, line 3, on back) ........................................................... 3 Gallons used for commercial gallonage during the period (add lines 1 and 2 - explain below) ........................ 4 Commercial gallonage reimbursement rate (see instructions) ............................................................................. 5 Refund requested (multiply line 3 by line 4) ............................................................................................................... Explain how gallonage reported on line 3 was used

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Certification: I, the claimant, or an officer or authorized representative of the claimant, do hereby make application for reimbursement of the petroleum business tax pursuant to New York State Tax Law, and certify that to the best of my knowledge all New York State petroleum business taxes for which this claim has been filed have been paid; no portion of the tax has been reimbursed or credited to me by any vendor; and no items for which reimbursement or credit was previously claimed or received are included. I make these statements with the knowledge that willfully issuing a document known to be false or fraudulent as to any material matter is a misdemeanor under section 1812-f(c)(2) of the New York State Tax Law and section 210.45 of the Penal Law, punishable by a fine up to $10,000 for an individual or $20,000 for a corporation. Signature Preparer's signature Firm's name (or yours, if self-employed) Address ZIP code Power of attorney attached Date Title FEIN or social security number Date Telephone number

Paid Preparer's Use Only

Yes

No

Privacy notification -- The Commissioner of Taxation and Finance may collect and maintain personal information pursuant to the New York State Tax Law, including but not limited to, sections 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and 1415 of that Law; and may require disclosure of social security numbers pursuant to 42 USC 405(c)(2)(C)(i). This information will be used to determine and administer tax liabilities and, when authorized by law, for certain tax offset and exchange of tax information programs as well as for any other lawful purpose. Information concerning quarterly wages paid to employees is provided to certain state agencies for purposes of fraud prevention, support enforcement, evaluation of the effectiveness of certain employment and training programs and other purposes authorized by law. Failure to provide the required information may subject you to civil or criminal penalties, or both, under the Tax Law. This information is maintained by the Director of the Registration and Data Services Bureau, NYS Tax Department, Building 8, Room 338, W A Harriman Campus, Albany NY 12227; telephone 1 800 225-5829. From areas outside the United States and Canada, call (518) 485-6800. Mail to: NYS TAX DEPARTMENT FUEL TAX REFUND UNIT P O BOX 5501 ALBANY NY 12205-5501

AU-473 (10/01)(back)
Date of purchase

Schedule A - Diesel Motor Fuel (Unenhanced) Purchases
(Attach additional sheets if necessary.)
Seller's Name City County Invoice number Number of gallons Excise tax paid Petroleum business tax paid Sales tax paid

1 Total gallons (add the number of gallons above) ..........................................

1

2 Gallons used for other purposes (noncommercial gallonage) ............. 2 3 Gallons used for commercial gallonage (subtract line 2 from line 1; also enter on page 1, line 1) ........................................................... 3

Schedule B - Residual Petroleum Product Purchases
(Attach additional sheets if necessary.)
Date of purchase Seller's Name City County Invoice number Number of gallons Petroleum business tax paid Sales tax paid

1 Total gallons (add the number of gallons above) ..........................................

1

2 Gallons used for other purposes (noncommercial gallonage) ............ 2 3 Gallons used for commercial gallonage (subtract line 2 from line 1; also enter on page 1, line 2) ........................................................... 3